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Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline. Ann Oncol 2023; 34:452-467. [PMID: 36638869 DOI: 10.1016/j.annonc.2022.12.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 01/11/2023] Open
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Baseline characteristics of patients with atrial fibrillation and cancer enrolled in the BLITZ-AF Cancer registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy.
Methods
BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing.
Results
From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled.
The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases.
AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF.
Baseline characteristics are presented in Table 1. Males were more than women and almost half of the subjects was >75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3.
As shown in Figure 1, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined.
Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22–2.05), age (OR 2.00, 95% CI 1.39–2.88 and OR 2.63, 95% CI 1.84–3.76, respectively, for 65–74 years and ≥75 years vs <65 years), hypertension (OR 1.43, 95% CI 1.10–1.87), long-standing persistent or permanent AF (OR 1.36, 95% CI 1.05–1.78). Haemoglobin <12 g/dL (OR 0.57, 95% CI 0.45–0.73), and planned cancer treatment (OR 0.72, 95% CI 0.57–0.92) were independently associated with a lower prescription of DOACs.
Conclusions
BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo.
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TAPSE or right-to-lleft ventricle diameter ratio at echocardiography to predict death in patients with acute pulmonary embolism: a meta-analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Right ventricle (RV) dysfunction at echocardiography is a recognized predictor of death or clinical deterioration in patients with acute pulmonary embolism (PE). However, the best predictor of death among echo parameters of RV dysfunction is unknown.
Purpose
This meta-analysis is aimed at assessing the role of individual parameter of RV dysfunction at echocardiography to predict all-cause short-term death in patients with acute PE.
Methods
OVID was searched between 1993 and January 2020 for studies i) including patients with confirmed acute PE; ii) reporting on RV assessment at echocardiography at admission; iii) reporting on short-term all-cause or PE-related death. The primary study outcome is short-term (30 days or in-hospital) all-cause mortality.
Results
We report here on the role of tricuspid annular plane excursion (TAPSE) and right-to-left ventricle diameter ratio (RV/LV) at echocardiography as predictors of short-term death in patients with acute PE. TAPSE. Abnormal TAPSE at echocardiography was associated with increased risk for short-term death in all-comers with acute PE (eight studies; 3298 patients; RR 2.78 CI 95% 0.53–14.63; Figure 1) and in hemodynamically stable patients (six studies; 3013 patients; RR 2.76 CI 95% 1.44–5.30 I2 58%). The association is confirmed for different cut-off values of TAPSE (≥15mm or any cut-off value >15mm). RV/LV. In eight studies reporting on continuous measures, the difference between mean right and left ventricle diameter at echocardiography in patients who died vs those who survived ranged from 0.02 to 0.3 mm. Abnormal RV/LV ratio at echocardiography was not associated with increased risk for short-term death in all-comers with acute PE (six studies; 2292 patients; RR 1.48 CI 95% 0.43–5.08), nor in hemodynamically stable patients (four studies; 1014 patients; RR 1.20 CI 95% 0.72–1.99, I2=0%).
Conclusion
Abnormal TAPSE is associated with short-term death in patients with acute PE. In these patients, the prognostic role of RV/LV diameter ratio as stand-alone parameter of RV dysfunction at echocardiography remains unclear.
Funding Acknowledgement
Type of funding sources: None. Figure 1. Association between TAPSE and all-cause
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OC-14 Risk factors for recurrence in patients with cancer-associated venous thromboembolism: results from the Hokusai-VTE cancer study. Thromb Res 2021. [DOI: 10.1016/s0049-3848(21)00156-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases. J Intern Med 2021; 289:325-339. [PMID: 32445216 DOI: 10.1111/joim.13114] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Lemierre syndrome is characterized by head/neck vein thrombosis and septic embolism usually complicating an acute oropharyngeal bacterial infection in adolescents and young adults. We described the course of Lemierre syndrome in the contemporary era. METHODS In our individual-level analysis of 712 patients (2000-2017), we included cases described as Lemierre syndrome if these criteria were met: (i) primary site of bacterial infection in the head/neck; (ii) objectively confirmed local thrombotic complications or septic embolism. The study outcomes were new or recurrent venous thromboembolism or peripheral septic lesions, major bleeding, all-cause death and clinical sequelae. RESULTS The median age was 21 (Q1-Q3: 17-33) years, and 295 (41%) were female. At diagnosis, acute thrombosis of head/neck veins was detected in 597 (84%) patients, septic embolism in 582 (82%) and both in 468 (80%). After diagnosis and during in-hospital follow-up, new venous thromboembolism occurred in 34 (5.2%, 95% CI 3.8-7.2%) patients, new peripheral septic lesions became evident in 76 (11.7%; 9.4-14.3%). The rate of either was lower in patients who received anticoagulation (OR: 0.59; 0.36-0.94), higher in those with initial intracranial involvement (OR: 2.35; 1.45-3.80). Major bleeding occurred in 19 patients (2.9%; 1.9-4.5%), and 26 died (4.0%; 2.7-5.8%). Clinical sequelae were reported in 65 (10.4%, 8.2-13.0%) individuals, often consisting of cranial nerve palsy (n = 24) and orthopaedic limitations (n = 19). CONCLUSIONS Patients with Lemierre syndrome were characterized by a substantial risk of new thromboembolic complications and death. This risk was higher in the presence of initial intracranial involvement. One-tenth of survivors suffered major clinical sequelae.
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Effects of body composition on the procoagulant imbalance in obese patients. J Thromb Thrombolysis 2020; 51:1036-1042. [PMID: 32968849 DOI: 10.1007/s11239-020-02287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
Obesity is associated with increased thrombotic risk and hypercoagulability whose main driver is an excess of coagulation factor VIII relative to protein C. The aims of this study were to evaluate the association between factor VIII, protein C, factor VIII-to-protein C ratio and bioimpedance parameters of body composition in obese patients. We analysed blood from 69 obese patients and 23 non-obese healthy controls. Plasma levels of factor VIII, protein C, and factor VIII-to-protein C ratio were correlated with total fat, visceral fat, and muscle mass. Compared to controls, obese patients had significantly higher factor VIII (110.5% vs 78.05%, p < 0.001), protein C (120.99% versus 110.51%, p = 0.014), and factor VIII-to-protein C ratio (0.93 versus 0.73, p = 0.002). In obese patients, factor VIII correlated with body-mass index, body fat percentage, muscle mass percentage, and fat-to-muscle ratio, whereas protein C had significant relationships with body fat percentage, muscle mass percentage and fat-to-muscle ratio, but not with body-mass index. Factor VIII-to-protein C ratio > 1 was significantly associated with body-mass index (odds ratio 1.08, 95% CI 1.02 to 1.14) and fat-to-muscle ratio (odds ratio 2.47, 95% CI 1.10 to 5.55). Factor VIII-to-protein C ratio strongly correlated with D-dimer levels in the overall population (rho 0.44, p < 0.001) and obese patients (rho 0.41, p < 0.001). In obese patients, bioimpedance measures of body fat and muscle mass percentage were associated with factor VIII and protein C. Factor VIII-to-protein C ratio was strongly associated with fat-to-muscle ratio and only modestly related to BMI.
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Corrigendum to “Edoxaban for treatment of venous thromboembolism in patient groups with different types of cancer: Results from the Hokusai VTE Cancer study” [Thromb. Res. vol. 185, January 2020, pages 13–19]. Thromb Res 2020; 191:156-159. [DOI: 10.1016/j.thromres.2020.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Edoxaban for treatment of venous thromboembolism in patient groups with different types of cancer: Results from the Hokusai VTE Cancer study. Thromb Res 2019; 185:13-19. [PMID: 31733403 DOI: 10.1016/j.thromres.2019.11.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The safety and efficacy of edoxaban and dalteparin is unclear for several cancer groups. METHODS We evaluated the occurrence of the primary outcome in large cancer groups. The primary outcome was the composite of recurrent VTE or major bleeding over 12 months. RESULTS In patients with gastrointestinal cancer, the primary outcome occurred in 19.4% patients given edoxaban and in 15.0% given dalteparin (risk difference [RD], 4.4%; 95%-CI, -4.1% to 12.8%). The corresponding rates for edoxaban and dalteparin were 10.4% and 10.7% for lung cancer (RD, -0.3%; 95%-CI, -10.0% to 9.5%), 13.6% and 12.5% for urogenital cancer (RD, 1.1; 95%-CI, -10.1-12.4), 3.1% and 11.7% for breast cancer (RD, -8.6; 95%-CI, -19.3-2.2), 8.9% and 10.9% for hematological malignancies (RD, -2.0; 95%-CI, -13.1-9.1), and 10.4% and 17.4% for gynecological cancer (RD, -7.0; 95%-CI, -19.8-5.7). In the subgroup of gastrointestinal cancer, edoxaban was associated with a 3.5% lower absolute risk of recurrent VTE and a 7.9% higher risk of major bleeding. CONCLUSION Edoxaban has a similar risk-benefit ratio to dalteparin in most cancer groups. In those with gastrointestinal cancer, the lower risk of recurrent VTE and the advantages of oral therapy need to be balanced against the increased risk of major bleeding.
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Venous thromboembolism in cancer patients receiving neoadjuvant chemotherapy: a systematic review and meta-analysis. J Thromb Haemost 2018; 16:1336-1346. [PMID: 29754426 DOI: 10.1111/jth.14149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 01/19/2023]
Abstract
Essentials Cancer patients are at risk for venous thromboembolism (VTE). The risk of VTE in less advanced stage cancer on neoadjuvant chemotherapy is unclear. In over 7800 patients, we found a 7% pooled incidence of VTE during neoadjuvant therapy. Highest VTE rates were observed in patients with bladder and esophageal cancer. SUMMARY Background Venous thromboembolism (VTE) is a frequent complication in cancer patients receiving adjuvant treatment. The risk of VTE during neoadjuvant chemo-radiotherapy remains unclear. Objectives This systematic review evaluated the incidence of VTE in patients with cancer receiving neoadjuvant treatment. Methods MEDLINE and EMBASE databases were searched from inception to October 2017. Search results were supplemented with screening of conference proceedings of the American Society of Clinical Oncology (2009-2016) and the International Society of Thrombosis and Haemostasis (2003-2016). Two review authors independently screened titles and abstracts, and extracted data onto standardized forms. Results Twenty-eight cohort studies (7827 cancer patients, range 11 to 1398) were included. Twenty-five had a retrospective design. Eighteen cohorts included patients with gastrointestinal cancer, representing over two-thirds of the whole study population (n = 6002, 78%). In total, 508 of 7768 patients were diagnosed with at least one VTE during neoadjuvant treatment, for a pooled VTE incidence of 7% (95% CI, 5% to 10%) in the absence of substantial between-study heterogeneity. Heterogeneity was not explained by site of cancer or study design characteristics. VTE presented as pulmonary embolism in 22% to 96% of cases (16 cohorts), and it was symptomatic in 22% to 100% of patients (11 cohorts). The highest VTE rates were observed in patients with bladder (10.6%) or esophageal (8.4%) cancer. Conclusions This review found a relatively high incidence of VTE in cancer patients receiving neoadjuvant therapy in the presence of some between-study variation, which deserves further evaluation in prospective studies.
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Treatment and long-term clinical outcomes of incidental pulmonary embolism in cancer patients: an international prospective cohort study. Thromb Res 2018. [DOI: 10.1016/j.thromres.2018.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Efficacy and safety of edoxaban in clinically relevant subgroups: results from the Hokusai VTE Cancer randomized trial. Thromb Res 2018. [DOI: 10.1016/j.thromres.2018.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Can we use the Khorana risk score to predict venous thromboembolism in patients with cancer? A systematic review and meta-analysis. Thromb Res 2018. [DOI: 10.1016/j.thromres.2018.02.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clinical course of isolated distal deep vein thrombosis in patients with active cancer: a multicenter cohort study. J Thromb Haemost 2017; 15:1757-1763. [PMID: 28639418 DOI: 10.1111/jth.13761] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Indexed: 11/28/2022]
Abstract
Essentials Isolated distal deep vein thrombosis (IDDVT) is frequently associated with cancer. No study has specifically evaluated the long-term clinical course of cancer-associated IDDVT. Patients with cancer-associated IDDVT are at very high risk of symptomatic recurrence and death. We observed low rates of major bleeding during anticoagulation. SUMMARY Background Although isolated distal deep vein thrombosis (IDDVT) is frequently associated with cancer, no study has specifically evaluated the long-term clinical course of IDDVT in this setting. Aim To provide data on the rate of recurrent venous thromboembolism (VTE), major bleeding events and death in IDDVT patients with active cancer. Patients and Methods Consecutive patients with active cancer and an objective IDDVT diagnosis (January 2011 to September 2014) were included from our files. We collected information on baseline characteristics, IDDVT location and extension, VTE risk factors, and type and duration of anticoagulant treatment. Results A total of 308 patients (mean age 66.2 [standard deviation (SD), 13.2 years]; 57.1% female) with symptomatic IDDVT and a solid (n = 261) or hematologic (n = 47) cancer were included at 13 centers. Cancer was metastatic in 148 (48.1%) patients. All but three (99.0%) patients received anticoagulant therapy, which consisted of low-molecular-weight heparin in 288 (93.5%) patients. Vitamin K antagonists were used for the long-term treatment in 46 (14.9%) patients, whereas all others continued the initial parenteral agent for a mean treatment duration of 4.2 months (SD, 4.6 months). During a total follow-up of 355.8 patient-years (mean, 13.9 months), there were 47 recurrent objectively diagnosed VTEs for an incidence rate of 13.2 events per 100 patient-years. During anticoagulant treatment, the annual incidence of major bleeding was 2.0 per 100 patient-years. Conclusions Cancer patients with IDDVT have a high risk of VTE recurrence. Additional studies are warranted to investigate the optimal intensity and duration of anticoagulant treatment for these patients.
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Is stand-alone D-dimer testing safe to rule out acute pulmonary embolism? J Thromb Haemost 2017; 15:323-328. [PMID: 27873439 DOI: 10.1111/jth.13574] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Indexed: 01/08/2023]
Abstract
Essentials A stand-alone D-dimer below 750 μg/L has been proposed to rule out acute pulmonary embolism (PE). This was a post-hoc analysis on data from 6 studies comprising 7268 patients with suspected PE. The negative predictive value of a D-dimer <750 μg/L ranged from 79% to 96% in various subgroups. Stand-alone D-dimer testing seems to be unsafe to rule out PE in all patients. SUMMARY Background Recently, stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 has been proposed as a safe and efficient approach to rule out acute pulmonary embolism (PE), without additional imaging, but this approach needs validation. Objectives To evaluate stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 to rule out PE. Methods Individual data from 7268 patients with suspected PE previously enrolled in six prospective management studies were used. Patients were assessed by the Wells rule followed by quantitative D-dimer testing in those with a 'PE unlikely' score. Patients were classified post hoc as having a negative (< 750 μg L-1 ) or positive (≥ 750 μg L-1 ) D-dimer. Using a one-stage meta-analytic approach, the negative predictive value (NPV) of stand-alone D-dimer testing was evaluated overall and in different risk subgroups. Results The pooled incidence of PE was 23% (range, 13-42%). Overall, 44% of patients had a D-dimer < 750 μg L-1 , of whom 2.8% were diagnosed with PE at baseline or during 3-month follow-up (NPV, 97.2%; 95% confidence interval [CI], 94.9-98.5). The NPV was highest in patients with a low probability of PE according to the Wells rule (99.2%; 95% CI, 98.6-99.5%) and lowest in those with a high probability of PE (79.3%; 95% CI, 53.0-92.8%). The NPVs in patients with active cancer, patients with previous venous thromboembolism and inpatients were 96.2% (95% CI, 85.6-99.1%), 94.7% (95% CI, 88.6-97.6%) and 92.7% (95% CI, 79.3-97.7%), respectively. Conclusions Our findings suggest that stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 is not safe to rule out acute PE.
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Improving the diagnostic management of upper extremity deep vein thrombosis. J Thromb Haemost 2017; 15:66-73. [PMID: 27732764 DOI: 10.1111/jth.13536] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/23/2016] [Indexed: 11/26/2022]
Abstract
Essentials The Constans score and D-dimer can rule out upper extremity deep vein thrombosis without imaging. We evaluated the performance of an extended Constans score and an age-adjusted D-dimer threshold. The extended Constans score did not increase the efficiency compared to the original score. Age-adjusted D-dimer testing safely increased the efficiency by 4%, but this needs validation. SUMMARY Background Among patients with clinically suspected upper extremity deep vein thrombosis (UEDVT), a clinical decision rule based on the Constans score combined with D-dimer testing can safely rule out the diagnosis without imaging in approximately one-fifth of patients. Objectives To evaluate the performance of the original Constans score, an extended Constans score and an age-adjusted D-dimer positivity threshold. Methods Data of 406 patients with suspected UEDVT previously enrolled in a multinational diagnostic management study were used. The discriminatory performance, calibration and diagnostic accuracy of the Constans score were evaluated. The Constans score was extended by selecting clinical variables that may have incremental value in detecting UEDVT, conditional on the original Constans score items. The performance of the Constans rule was evaluated in combination with fixed and age-adjusted D-dimer thresholds. Results The original Constans score showed good discriminatory performance (c-statistic, 0.81; 95% confidence interval [CI], 0.76-0.85). An extended Constans score with five additional clinical items improved discriminatory performance and calibration, but this did not translate into a higher efficiency in avoiding imaging tests. Compared with a fixed threshold, age-adjusted D-dimer testing increased the proportion of patients for whom imaging and anticoagulation could be withheld from 21% to 25% (gain, 3.7%; 95% CI, 2.3-6.0%). Conclusions The Constans score has good discriminatory performance in the diagnosis of UEDVT. Age-adjusted D-dimer testing is likely to safely increase the efficiency of the diagnostic algorithm, but this approach needs prospective validation.
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Incidental pulmonary embolism in cancer patients: Interobserver agreement on the diagnosis and extent with a focus on distal clots. Thromb Res 2016; 147:46-51. [DOI: 10.1016/j.thromres.2016.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/11/2016] [Accepted: 09/14/2016] [Indexed: 12/28/2022]
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Current management strategies and long-term clinical outcomes of upper extremity venous thrombosis. J Thromb Haemost 2016; 14:973-81. [PMID: 26866515 DOI: 10.1111/jth.13291] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/04/2016] [Indexed: 01/17/2023]
Abstract
UNLABELLED Essentials Few data exist on outcome of upper extremity deep and superficial vein thrombosis (UEDVT and UESVT). We followed 102 and 55 patients with UEDVT or UESVT, respectively, for a median of 3.5 years. Risk of recurrent venous thromboembolism was low in both diseases, and the mortality high. Postthrombotic symptoms were infrequent and cancer patients had a higher risk of recurrent VTE. SUMMARY Background There is scant information on the optimal management and clinical outcome of deep and superficial vein thrombosis of the upper extremity (UEDVT and UESVT). Objectives To explore treatment strategies and the incidence of recurrent venous thromboembolism (VTE), mortality, postthrombotic symptoms, and bleeding in patients with UEDVT and UESVT and to assess the prognosis of cancer patients with UEDVT. Patients/methods Follow-up of patients with UEDVT or UESVT, who were enrolled previously in a diagnostic management study. Results We followed 102 and 55 patients with UEDVT and UESVT, respectively, both for a median of 3.5 years. Anticoagulant treatment was started in 100 patients with UEDVT (98%) and in 40 (73%) with UESVT. Nine patients with UEDVT (9%) developed recurrent VTE, 26 (26%) died, 6 (8%) of 72 patients had moderate postthrombotic symptoms, and 5 (5%) experienced major bleeding. One patient with UESVT had a recurrent VTE, 18 (33%) died, none had moderate postthrombotic symptoms, and none had major bleeding. Of the cancer patients with UEDVT, 18% had recurrent VTE vs. 7.5% in non-cancer patients (adjusted hazard ratio 2.2, 95%CI 0.6-8.2). The survival rate was 50% in cancer patients with UEDVT vs. 60% in those without (adjusted HR 0.8, 95%CI 0.4-1.4). Conclusions The risk of recurrent VTE was low in patients with UEDVT, and negligible for UESVT. Mortality was high for both diseases. Postthrombotic symptoms were infrequent and mild. Anticoagulant therapy of UEDVT carried a substantial risk of major bleeding. Cancer patients had a significant risk of recurrent VTE.
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ADAMTS-13 and von Willebrand factor predict venous thromboembolism in patients with cancer. J Thromb Haemost 2016; 14:306-15. [PMID: 26589836 DOI: 10.1111/jth.13205] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 10/16/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED ESSENTIALS: Cancer patients are at high risk of venous thromboembolism (VTE). In this study, cases and controls were cancer patients who did or did not develop VTE. von Willebrand factor (VWF) levels were higher if compared with controls and correlated with cancer stage. VWF and ADAMTS-13 are associated with the occurrence of VTE in cancer. BACKGROUND Patients with cancer are at high risk of venous thromboembolism (VTE). ADAMTS-13 regulates von Willebrand factor (VWF) activity, which plays a role in the development of cancer and in VTE. OBJECTIVES The aim of this study was to search for an association between the levels of VWF and ADAMTS-13 and VTE in patients with cancer and to compare current scoring systems for prediction of VTE before and after addition of these parameters. PATIENTS/METHODS In a case-control study, in which patients with recently diagnosed cancer were followed-up for 6 months, we compared 20 patients who developed VTE (cases) and 140 patients with cancer without VTE (controls), matched for sex, age, and type and stage of cancer. We measured VWF, ADAMTS-13 (activity and antigen), P-selectin, D-dimer and F1 + 2 levels at baseline, and calculated both the Khorana score and the Khorana score expanded after addition of P-selectin and D-dimer levels. RESULTS VWF levels were significantly higher in cases when compared with controls (326 ± 185% vs. 242 ± 158%) and correlated with advanced stage of cancer: localized, 185 [142; 222]; locally advanced, 240 [146; 257]; metastatic, 267 [153; 324] (mean [interquartile range]). The addition of two biomarkers, ADAMTS-13 activity and F1 + 2 levels, to the Khorana score improved receiver operating curves. CONCLUSIONS von Willebrand factor and ADAMTS-13 are associated with the occurrence of VTE in patients with cancer. Moreover, addition of ADAMTS-13 and F1 + 2 levels to the Khorana score considerably increases the predictive value for VTE.
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Management of cancer-associated disseminated intravascular coagulation: guidance from the SSC of the ISTH: reply. J Thromb Haemost 2015; 13:1352-3. [PMID: 25854143 DOI: 10.1111/jth.12962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 04/06/2015] [Indexed: 11/29/2022]
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Diagnosis and treatment of incidental venous thromboembolism in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost 2015; 13:880-3. [PMID: 25714858 DOI: 10.1111/jth.12883] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/19/2015] [Indexed: 11/28/2022]
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Management of cancer-associated disseminated intravascular coagulation: guidance from the SSC of the ISTH. J Thromb Haemost 2015; 13:671-5. [PMID: 25556711 DOI: 10.1111/jth.12838] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Indexed: 01/13/2023]
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Anticoagulant treatment of cancer patients with pulmonary embolism in the real world. Actual use of low-molecular-weight heparin in cancer. Neth J Med 2014; 72:467-472. [PMID: 25431392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Since 2004, guidelines recommend long-term treatment with low-molecular-weight heparin (LMWH) in patients with cancer and pulmonary embolism (PE). We assessed the proportion of cancer patients with PE actually treated with LMWH and the duration of anticoagulant treatment in the Netherlands. METHODS A retrospective cohort study in patients that were hospitalised for PE between 1998-2008. Patients with PE were selected from national hospital discharge records, after linkage to a national pharmacy database. Cancer patients with PE were matched for age, sex and year of diagnosis of PE to subjects with PE without cancer. RESULTS 600 cancer patients with PE were matched to 1200 patients with PE without cancer. Long-term LMWH was prescribed in 82 (13.7%) of the cancer patients and in eight (0.7%) of the cancer-free patients (p < 0.001); all the other patients received vitamin K antagonists (VKA). From 1998-2008, there was an increase in the use of LMWH in cancer patients: in 2007-2008, LMWH was prescribed in 42 (32%) cases, compared with one (1.7%) of the cancer patients with PE in 1998-1999. Median duration of treatment was 5.8 months (interquartile range 3.1-8.8) in cancer patients, compared with 7.0 months (4.9-11) in patients without cancer (p < 0.001), a difference that persisted after adjustment for mortality. CONCLUSIONS Although the use of LMWH in patients with cancer and PE is increasing, in 2008, patients in the Netherlands are still mostly treated with VKA, and not with LMWH as recommended by guidelines. Cancer patients with PE on average receive shorter treatment than matched patients without cancer.
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Prevention of venous thromboembolism in hospitalized medical cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost 2014; 12:1746-9. [PMID: 25099690 DOI: 10.1111/jth.12683] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 07/29/2014] [Indexed: 12/15/2022]
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Safety and Feasibility of a Diagnostic Algorithm Combining Clinical Probability, D-Dimer Testing, and Ultrasonography for Suspected Upper Extremity Deep Venous Thrombosis: A Prospective Management Study. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Harmonized guidance for disseminated intravascular coagulation from the International Society on Thrombosis and Haemostasis and the current status of anticoagulant therapy in Japan: a rebuttal. J Thromb Haemost 2013; 11:2078-9. [PMID: 23927431 DOI: 10.1111/jth.12366] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines. J Thromb Haemost 2013; 11:S1538-7836(22)13716-5. [PMID: 23379279 DOI: 10.1111/jth.12155] [Citation(s) in RCA: 270] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Three guidelines have recently been published for the diagnosis and treatment of disseminated intravascular coagulation (DIC) in adults. This communication seeks to harmonize the recommendations in these guidelines using a modified GRADE system. The scoring system for diagnosis of DIC using global coagulation tests is known to correlate with key clinical observations and outcomes (Moderate quality). The cornerstone of DIC treatment is the treatment of the underlying condition (Moderate quality). In general, transfusion of platelets or plasma (components) in patients with DIC should be reserved for patients who are bleeding (Low quality). Therapeutic doses of heparin should be considered in cases of DIC where clinical features of thrombosis predominate. Heparin is not recommended in those patients with a high risk of bleeding, (Moderate quality). However, prophylactic doses of unfractionated heparin or low molecular we ight heparin is recommended in critically ill and non-bleeding patients with DIC for prevention of venous thromboembolism (Moderate to High quality). Although further prospective evidence from randomized controlled trials is required, administration of antithrombin or recombinant thrombomodulin may be considered in certain patients with DIC. In general, patients with DIC should not be treated with antifibrinolytic agents (Low quality). However those who present with severe bleeding, that is characterized by a markedly hyperfibrinolytic state such as leukemia (Low quality) and trauma (Moderate quality), may be treated with antifibrinolytic agents. © 2013 International Society on Thrombosis and Haemostasis.
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Safety and efficacy of low-dose fondaparinux (1.5 mg) for the prevention of venous thromboembolism in acutely ill medical patients with renal impairment: the FONDAIR study. J Thromb Haemost 2012; 10:2291-7. [PMID: 22925036 DOI: 10.1111/j.1538-7836.2012.04908.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Renal impairment is common, affecting around 40% of acutely ill medical patients, and is associated with an increased risk of both venous thromboembolism (VTE) and bleeding. The clinical benefit of effective thromboprophylactic strategies may be outweighed in these patients by an excessive rate of hemorrhage. OBJECTIVE To assess the safety and efficacy of lower prophylactic doses of fondaparinux in acutely ill medical patients with renal impairment. PATIENTS/METHODS We carried out a multicenter, investigator-initiated, prospective cohort study. Patients at risk of VTE with a creatinine clearance between 20 and 50 mL min(-1) were treated with fondaparinux 1.5 mg qd for a minimum of 6 to a maximum of 15 days. The primary outcome was the incidence of major bleeding; secondary outcomes were clinically relevant non-major bleeding (CRNMB) and symptomatic VTE. RESULTS We enrolled 206 patients with a mean age of 82 years, mean creatinine clearance of 33 mL min(-1) , and a mean Charlson co-morbidity index of 8.2. One patient had major bleeding (0.49%, 95% confidence interval [CI] 0.03-3.10), eight had CRNMB (3.88%, 95% CI 1.81-7.78) and three developed symptomatic VTE (1.46%, 0.38-4.55). Twenty-three patients (11.17%, 7.36-16.48) died. No independent predictors of bleeding were found at univariate analysis. CONCLUSIONS The addition of moderate to severe renal impairment to patients with traditional risk factors for VTE identified a population of very elderly acutely ill medical patients potentially at high risk of both VTE and bleeding complications. The recently approved lower prophylactic dose of fondaparinux appears to be a safe and relatively effective strategy in these patients.
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Abstract
OBJECTIVE To assess the efficacy of tirofiban in comparison to usual care or other GPIIb/IIIa antagonists (eptifibatide and abciximab). Results were analysed by drug administration with planned percutaneous coronary intervention (PCI) or as medical management without planned PCI, and separately for STEMI or NSTE ACS patients. RESEARCH DESIGN AND METHODS A systematic review was performed of randomized controlled trials of tirofiban, abciximab, eptifibatide or usual care given to patients with acute coronary syndrome. Nine databases were searched up to March 2010. Pair-wise meta-analysis was used to combine all available direct comparisons; indirect comparisons and network analysis were performed when this was not possible. The primary outcome was MACE (major adverse cardiac event). RESULTS The search yielded 8, 119 records and 50 trials were included (total number of patients = 52,958). Compared to usual care, high and medium-dose tirofiban (25 and 10 µg/kg/min) administered with planned PCI reduced MACE at 30 days for patients with STEMI (RR 0.67, 95% CI 0.45, 0.99; RR 0.28, 95% CI 0.10, 0.80), but was not effective as a medical management. Medium-dose tirofiban (10 µg/kg/min) administered with planned PCI or low dose (0.4 µg/kg/min) as medical management reduced the risk of MACE for patients with NSTE ACS (RR 0.39, 95% CI 0.21, 0.75; RR 0.58, 95% CI 0.41, 0.83) in comparison to usual care, but at the expense of increased thrombocytopenia (RR 3.26, 95% CI 1.31, 8.13). Evidence from RCTs and network analysis indicated tirofiban and abciximab were equally effective and safe. Comparing tirofiban and eptifibatide treatment by indirect and network analysis produced inconclusive results. CONCLUSIONS Tirofiban was more effective than usual care for STEMI and NSTE ACS patients receiving planned PCI, and NSTE ACS patients receiving medical management. Tirofiban and abciximab were equally effective. Comparisons of tirofiban and eptifibatide were inconclusive.
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PO-67 Long-term treatment for cancer patients with deep vein thrombosis or pulmonary embolism – a randomized controlled trial. Thromb Res 2010. [DOI: 10.1016/s0049-3848(10)70117-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis: a systematic review. J Thromb Haemost 2010; 8:684-92. [PMID: 20141579 DOI: 10.1111/j.1538-7836.2010.03771.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The best available test for the diagnosis of upper extremity deep venous thrombosis (UEDVT) is contrast venography. The aim of this systematic review was to assess whether the diagnostic accuracy of other tests for clinically suspected UEDVT is high enough to justify their use in clinical practise and to evaluate if any test can replace venography. METHODS MEDLINE and EMBASE databases were searched from inception to June 2009. Two reviewers independently evaluated study eligibility, extracted data, and assessed study quality. RESULTS We identified 17 papers, reporting on 793 patients. Overall, the methodological quality was poor, sample sizes were small, and large between-study differences were observed in spectrum and design. The summary estimates of sensitivity (95% confidence interval) were 97% (90-100%) for compression ultrasonography, 84% (72-97%) for Doppler ultrasonography, 91% (85-97%) for Doppler ultrasonography with compression, and 85% (72-99%) for phleboreography. The corresponding summary estimates of specificity were, respectively, 96% (87-100%), 94% (86-100%), 93% (80-100%), and 87% (71-100%). Clinical findings, a clinical score, D-dimer, magnetic resonance imaging, rheography and plethysmography were evaluated in one study each, involving a median number of 46 patients (range 21-214). Sensitivity and specificity ranged from 0% to 100% and from 14% to 100%. CONCLUSIONS Methodological limitations, large between-study differences and small sample sizes limit the evidence of tests for clinically suspected UEDVT. Compression ultrasonography may be an acceptable alternative to venography. The addition of (color) Doppler does not seem to improve the accuracy. Adequately designed studies are warranted to confirm these findings.
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PO-06 Asymptomatic venous thromboembolism in patients with solid tumors treated with chemotherapy: An underestimated phenomenon. Thromb Res 2010. [DOI: 10.1016/s0049-3848(10)70056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cell-derived microvesicles and cancer. Neth J Med 2009; 67:266-273. [PMID: 19687520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Blood and other body f luids contain cell-derived microvesicles. The presence of microvesicles in cancer patients was already noticed in the late 1970s. Since then, the prothrombotic state in cancer patients has invariably been associated with the presence of such microvesicles. More recently, a growing body of evidence supports an important contribution of microvesicles to cancer cell survival, invasiveness and metastases. Here, we will present an overview of the many contributions of microvesicles to cancer development and progression. In addition, their role in risk stratification and treatment of cancer patients is discussed.
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Prevention of catheter-related venous thrombosis with nadroparin in patients receiving chemotherapy for hematologic malignancies: a randomized, placebo-controlled study. J Thromb Haemost 2007; 5:1878-82. [PMID: 17723127 DOI: 10.1111/j.1538-7836.2007.02660.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hemato-oncology patients treated with intensive chemotherapy usually require the placement of a central venous catheter (CVC). CVCs are frequently complicated by catheter-related central venous thrombosis (CVT), which has been associated with an increased risk of pulmonary embolism and catheter-related infection. OBJECTIVES To determine the efficacy and safety of thromboprophylaxis with s.c. low-molecular-weight heparin (nadroparin) administered once daily in a randomized placebo-controlled, double-blind trial in patients with hematologic malignancies. PATIENTS AND METHODS Consecutive patients with hematologic malignancies requiring intensive chemotherapy including autologous stem cell transplantation were eligible. The patients were randomized to receive nadroparin 2850 antifactor Xa units once daily or placebo s.c. for 3 weeks. Venography was performed on day 21 after CVC insertion. Secondary outcomes were bleeding and catheter-related infection. RESULTS In total, 113 patients were randomized to nadroparin or placebo, and 87 patients (77%) underwent venography. In total, 11 venographically proven catheter-related CVTs were diagnosed. The frequency of catheter-related CVT was not significantly different between study groups, namely four catheter-related CVTs in the placebo group [9%; 95% CI: 0.002-0.16] vs. seven catheter-related CVTs in the nadroparin group (17%; 95% CI: 0.06-0.28). In addition, no difference in the incidence of catheter-related infection or bleeding was observed between the groups. CONCLUSION This study showed that the actual risk for catheter-related CVT in patients with hematologic malignancies is lower than suggested in earlier studies in cancer patients. Although prophylactic administration of nadroparin appeared to be safe in this group of patients with a high risk of bleeding, it cannot be recommended for the prevention of catheter-related CVT or catheter-related infection in patients with hematologic malignancies.
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases Group searched their specialized register (last searched 16 February 2007), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 1, 2007. We searched MEDLINE (1966 to January 2006), EMBASE (1980 to January 2006), and handsearched reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomized trials evaluating topical, medical, and surgical treatments for ST of the leg including participants with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in the superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were extracted independently from the included studies and any disagreements resolved by consensus. MAIN RESULTS Twenty-four studies involving 2469 participants with ST of the legs were included in this review. The methodological quality of most of the trials was poor. Treatment ranged from low molecular weight heparin (LMWH), to non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, surgery, oral, intramuscular, and intravenous treatments. Both LMWH and NSAIDs significantly reduced the incidence of ST extension or recurrences by about 70% compared with placebo and both seemed to have a similar efficacy and safety. Overall, topical treatments improved local symptoms. However, no data were provided on the effects of these treatments on VTE and ST extension. Surgical treatment combined with elastic stockings in ST was associated with a lower VTE rate and ST progression, compared with elastic stockings alone. AUTHORS' CONCLUSIONS Low molecular weight heparin and NSAIDs appear as the current best therapeutic options for ST of the legs. While the available data are too limited to make clear recommendations, an intermediate dose of LMWH for at least a month might be advised. Further research is needed to assess the role of NSAIDs and LMWH, the optimal doses and duration of treatment, and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Abstract
BACKGROUND The reported diagnostic accuracy of the D-dimer test for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE) varies. It is unknown to what extent this is due to differences in study design or patient groups, or to genuine differences between D-dimer assays. METHODS Studies evaluating the diagnostic accuracy of the D-dimer test in the diagnosis of venous thromboembolism were systematically searched for in the MEDLINE and EMBASE databases up to March 2005. Reference lists of all included studies and of reviews related to the topic of the present meta-analysis were manually searched for other additional potentially eligible studies. Two reviewers independently extracted study characteristics using standardized forms. RESULTS In total, 217 D-dimer test evaluations for DVT and 111 for PE were analyzed. Several study design characteristics were associated with systematic differences in diagnostic accuracy. After adjustment for these features, the sensitivities of the D-dimer enzyme-linked immunofluorescence assay (ELFA) (DVT 96%; PE 97%), microplate enzyme-linked immunosorbent assay (ELISA) (DVT 94%; PE 95%), and latex quantitative assay (DVT 93%; PE 95%) were superior to those of the whole-blood D-dimer assay (DVT 83%; PE 87%), latex semiquantitative assay (DVT 85%; PE 88%) and latex qualitative assay (DVT 69%; PE 75%). The latex qualitative and whole-blood D-dimer assays had the highest specificities (DVT 99%, 71%; PE 99%, 69%). CONCLUSIONS Compared to other D-dimer assays, the ELFA, microplate ELISA and latex quantitative assays have higher sensitivity but lower specificity, resulting in a more confident exclusion of the disease at the expense of more additional imaging testing. These conclusions are based on the most up-to-date and extensive systematic review of the topic area, including 184 articles, with 328 D-dimer test evaluations.
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Abstract
BACKGROUND The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. OBJECTIVES To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases Group searched their specialized register (last searched October 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 4, 2006. We searched MEDLINE (1966 to January 2006), EMBASE (1980 to January 2006), and handsearched reference lists of relevant papers and conference proceedings. SELECTION CRITERIA Randomized trials evaluating topical, medical, and surgical treatments for ST of the leg including participants with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in the superficial vein. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were extracted independently from the included studies and any disagreements resolved by consensus. MAIN RESULTS Twenty-four studies involving 2469 participants with ST of the legs were included in this review. The methodological quality of most of the trials was poor. Treatment ranged from low molecular weight heparin (LMWH), to non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, surgery, oral, intramuscular, and intravenous treatments. Both LMWH and NSAIDs significantly reduced the incidence of ST extension or recurrences by about 70% compared with placebo and both seemed to have a similar efficacy and safety. Overall, topical treatments improved local symptoms. However, no data were provided on the effects of these treatments on VTE and ST extension. Surgical treatment combined with elastic stockings in ST was associated with a lower VTE rate and ST progression, compared with elastic stockings alone. AUTHORS' CONCLUSIONS Low molecular weight heparin and NSAIDs appear as the current best therapeutic options for ST of the legs. While the available data are too limited to make clear recommendations, an intermediate dose of LMWH for at least a month might be advised. Further research is needed to assess the role of NSAIDs and LMWH, the optimal doses and duration of treatment, and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.
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Combined use of clinical pretest probability and D-dimer test in cancer patients with clinically suspected deep venous thrombosis. J Thromb Haemost 2006; 4:52-7. [PMID: 16409449 DOI: 10.1111/j.1538-7836.2005.01671.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The value of the D-dimer (DD) test in combination with the clinical pretest probability (PTP) has not been evaluated in cancer patients with suspected deep vein thrombosis (DVT), whereas this group of patients usually accounts for 10-25% of clinically suspected DVT. METHODS A cohort of 2066 consecutive patients with clinically suspected DVT was investigated. Patients were judged to be positive or negative for DVT according to the outcomes of serial compression ultrasound and a 3-month follow-up period with imaging test verification of the symptomatic cases. Diagnostic accuracy indices of the DD test according to the PTP score were assessed in patients with and without cancer. RESULTS Of the cohort, 244 (11%) were known to have cancer at presentation. A venous thromboembolic event was diagnosed in 41% of the patients with cancer and in 22% of the patients without malignancy. Among the cancer patients, 17% were considered to have a low PTP, 35% a moderate and 41% a high PTP. The negative predictive value (NPV) of the DD test was 100% (95% CI, 85-100) and 97% (95% CI, 88-99) among cancer patients with low PTP or low-moderate PTP. In the absence of malignancy, the corresponding NPV were 98% and 97%, respectively. The specificity of the DD test progressively decreased moving from the low to the higher PTP. CONCLUSIONS In cancer patients with clinically suspected DVT, a negative DD might be useful in excluding the diagnosis within the low or low-moderate PTP groups. More studies are warranted to confirm these findings.
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Abstract
BACKGROUND No data have been so far reported on the relationship between polymorphisms of LEP gene and cardiovascular disease. PATIENTS AND METHODS We genotyped a tetranucleotide repeat mapped in the 3'UTR of the LEP gene (LEP-tet) in 109 subjects with cardiovascular events and in 109 control subjects. RESULTS Univariate analysis and multivariate logistic regression analysis adjusted for age, gender, smoking status, history of hyperlipidemia, hypertension or diabetes showed not significant association between the genotype of the LEP-tet and cardiovascular diseases. Moreover, no differences were observed in the plasma leptin concentrations between cases and control subjects (22 +/- 19 vs 22 +/- 14 ng/ml, P = 0.52) and in relation to the LEP-tet classes or carriage of specific alleles (P = 0.76 for the association between LEP-tet classes and leptin levels in overall analysis). CONCLUSIONS In conclusion, our data do not support an association between the LEP-tet microsatellite polymorphism of the human LEP gene and cardiovascular diseases.
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Effects of high plasma lipoprotein (a) levels on tissue factor pathway inhibitor and the protein C pathway. J Thromb Haemost 2005; 3:2123-5. [PMID: 16102130 DOI: 10.1111/j.1538-7836.2005.01517.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The prognostic value of the D-dimer test in cancer patients treated with and without low-molecular-weight heparin. J Thromb Haemost 2005; 3:1531-3. [PMID: 15978112 DOI: 10.1111/j.1538-7836.2005.01413.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND The safety of a D-dimer (DD) measurement in cancer patients with clinically suspected pulmonary embolism (PE) is unclear. OBJECTIVES The aim of this study was to assess the accuracy of the DD test in consecutive patients with clinically suspected PE with and without cancer. METHODS The diagnostic accuracy of DD (Tinaquant D-dimer) was first retrospectively assessed in an unselected group of patients referred for suspected PE (n = 350). Subsequently, the predictive value of the DD was validated in a group of consecutive inpatients and outpatients with clinically suspected PE prospectively enrolled in a management study (n = 519). The results of the DD test in cancer patients were assessed according to the final diagnosis of PE and the 3-month clinical follow-up. RESULTS In the first study group, DD showed a sensitivity and a negative predictive value (NPV) of 100% and 100% in patients with cancer and 97% and 98% in those without malignancy, respectively. In the validation cohort, the sensitivity and NPV of DD were both 100% (95% CI 82%-100% and 72%-100%, respectively), whereas in patients without malignancy, the corresponding estimates were 93% (95% CI 87%-98%) and 97% (95% CI, 95%-99%), respectively. The specificity of DD was low in patients with (21%) and without cancer (53%). CONCLUSIONS A negative DD result safely excludes the diagnosis of PE in patients with cancer. Because of the low specificity, when testing 100 patients with suspected PE, a normal DD concentration safely excludes PE in 15 patients with cancer and in 43 patients without cancer.
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Abstract
BACKGROUND Since hypercoagulability might result in recurrent pregnancy loss, anticoagulant agents could potentially increase the live-birth rate in subsequent pregnancies in women with either inherited thrombophilia or unexplained pregnancy loss. OBJECTIVES To evaluate the efficacy and safety of anticoagulant agents, such as aspirin and heparin, in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (March 2004), the Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to March 2004), and EMBASE (1980 to March 2004). We scanned bibliographies of all located articles for any unidentified articles. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that assessed the effect of anticoagulant treatment on the live-birth rate in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias were eligible. Interventions included aspirin, unfractionated heparin, and low molecular weight heparin for the prevention of birth loss. One treatment could be compared with another or with placebo. DATA COLLECTION AND ANALYSIS Two authors assessed the trials for inclusion in the review and extracted the data. Data were entered into the Review Manager software and double checked. MAIN RESULTS Two studies (242 participants) were included in the review and for both of them data were extracted for the subgroups of women fulfilling the inclusion criteria of the review. In one study, 54 pregnant women with recurrent spontaneous abortion without detectable anticardiolipin antibodies were randomised to low-dose aspirin or placebo. Similar live-birth rates were observed with aspirin and placebo (relative risk (RR) 1.00, 95% confidence interval (CI) 0.78 to 1.29). In another study, a subgroup of 20 women who had had a previous fetal loss after the 20th week and had a thrombophilic defect were randomised to enoxaparin or aspirin. Enoxaparin treatment resulted in an increased live-birth rate, as compared to low-dose aspirin, RR 10.00, 95% CI 1.56 to 64.20). AUTHORS' CONCLUSIONS The evidence on the efficacy and safety of thromboprophylaxis with aspirin and heparin in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias is too limited to recommend the use of anticoagulants in this setting. Large, randomised, placebo-controlled trials are urgently needed.
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Anticoagulants for the treatment of recurrent pregnancy loss in women without antiphospholipid syndrome. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2004. [DOI: 10.1002/14651858.cd004734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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